SiT100T. Account information. Fully identify and document the following individual(s): Account type and classification (Select one)

Transcription

1 Declaration of Beneficial Ownership in a Legal Entity Identify and document all Settlor(s) / Grantor(s), Trustee(s), Beneficiaries, Club Members and Partners. Total ownership interest must equal 100. Append pages to accommodate additional Settlor(s)/Grantor(s), Trustee(s), Beneficiaries, Club Members and Partners. The information requested in this form is in compliance with regulatory requirements. A Account information Legal Entity name (for account number above) Legal Entity name (Beneficial Owner Name from the SiT100A form) Account type and classification (Select one) Investment Club (complete section D for all club members) Partnership (complete section D for all partners) Is the partnership an Active Entity or a Passive Entity (see Definition of Active and Passive Entity below) Written Trust (complete section B / C / D as applicable) Complex Trust Grantor Trust Simple Trust U.S. Trust (also complete a W-9 Request for Taxpayer Identification and Certification form) Is the trust an Active Entity or a Passive Entity (see Definition of Active and Passive Entity below not applicable for U.S. Trust) Definition of Active and Passive Entity Active Entity The entity is Non-U.S. and is not a financial institution; Entities for which less than 50 of the gross income for the preceding calendar year was passive income and less than 50 of the assets held by the entity during the preceding calendar year were assets that produced passive income; Corporations with shares that regularly trade on an established securities market; Government or international organizations or agencies thereof and registered charities. Passive Entity A passive entity is any entity that is neither a financial institution nor an active entity. Passive income is generally understood to include income from the mere holding of property, such as interest, dividends, rents and royalties. Definition of U.S. Person U.S. Persons include: U.S. citizens (including persons with dual citizenship), U.S. resident aliens, persons born in the U.S.A., U.S. lawful permanent residents (e.g. Green Card holders), entities incorporated or organized in the U.S.A. or persons who meet the Substantial Presence Test for U.S. Residency. Individuals and entities that are U.S. Persons must also complete a W-9 Request for Taxpayer Identification Number and Certification form. B Fully identify and document the following individual(s): i. Settlor(s)/Grantors(s). (also complete sections C for trustees and D for beneficiaries) (Settlor/Grantor being the person who establishes the trust) ii. Settlor(s)/Grantors(s) and Beneficiary(ies) same individual or entity. (also complete section C for trustees) (Beneficiary being the recipient of the assets of the trust) iii. Settlor(s)/Grantor(s) and Trustee(s) same Individual or entity. (also complete section D for beneficiaires) (Trustee manages the trust) iv. Settlor(s)/Grantor(s), Beneficiary(ies) and Trustee(s) same individual or entity. (complete section B only) Select one Settlor/Grantor Settlor/Grantor and Beneficiary same individual Settlor/Grantor and Trustee same individual Settlor/Grantor, Beneficiary and Trustee same individual Last name Are you a U.S. Person for tax purposes? No Yes (see Definition of U.S. Person above) You are a citizen of Canada U.S.A. Other country (specify): Original - Branch Copy - Client Scotia itrade (Order-Execution Only Accounts) is a division of Scotia Capital Inc. ( SCI ). SCI is a member of the Investment Industry Regulatory Organization of Canada and the Canadian Investor Protection Fund. Scotia itrade does not provide investment advice or recommendations and investors are responsible for their own investment decisions. Registered trademark of The Bank of Nova Scotia. Used under license. Page 1 of 6

2 Select one Settlor/Grantor Settlor/Grantor and Beneficiary same individual Settlor/Grantor and Trustee same individual Settlor/Grantor, Beneficiary and Trustee same individual Last name Are you a U.S. Person for tax purposes? No Yes (see Definition of U.S. Person above) You are a citizen of Canada U.S.A. Other country (specify): C Fully identify and document the following: i. Trustee(s) (Individual) ii. Trustee(s) and Beneficiary(ies) same Individual(s) iii. Corporate Trustee (Banks and/or trust companies. Complete 'Entity Name' and 'Evidence attached' sections only.) Select one Trustee (Individual) Trustee and Beneficiary same Individual Corporate Trustee (bank or trust company) Select one Trustee (Individual) Trustee and Beneficiary same Individual Corporate Trustee (bank or trust company) Original - Branch Copy - Client Page 2 of 6

3 Select one Trustee (Individual) Trustee and Beneficiary same Individual Corporate Trustee (bank or trust company) D Fully identify and document the following individual(s) and/or legal entity: i. Beneficiary(ies) ii. Club Member(s) iii. Partner(s) Select one Beneficiary (if Written Trust) Club Member (if Investment Club) Partner (if Partnership) Select one Individual Partnership* Written Trust* (*also complete section E) Corporation** Personal Holding** Non-Operating Private Company** (**also complete a SiT100A) Ownership Interest #1 Original - Branch Copy - Client Page 3 of 6

4 Select one Beneficiary (if Written Trust) Club Member (if Investment Club) Partner (if Partnership) Select one Individual Partnership* Written Trust* (*also complete section E) Corporation** Personal Holding** Non-Operating Private Company** (**also complete a SiT100A) Ownership Interest #2 Select one Beneficiary (if Written Trust) Club Member (if Investment Club) Partner (if Partnership) Select one Individual Partnership* Written Trust* (*also complete section E) Corporation** Personal Holding** Non-Operating Private Company** (**also complete a SiT100A) Ownership Interest #3 You are a citizen of (Individual)/Established in (Trust) Canada U.S.A. Other country (specify): Original - Branch Copy - Client Page 4 of 6

5 E Complete this section if you have identified in section D that a Partnership or Written Trust holds an ownership interest Indicate the corresponding number for the beneficial ownership interest as indicated in section D. For each entity ensure that all Beneficial Owners are identified and the total percentage of each entity equals 100. Where there are more beneficial owners, append additional Declaration of Beneficial Ownership in a Legal Entity forms. Ownership Select one Settlor/Grantor Settlor/Grantor and Beneficiary same individual Settlor/Grantor and Trustee same individual Interest # Settlor/Grantor, Beneficiary and Trustee same individual Beneficiary Partner (If Beneficiary or Partner is an Entity, append additional completed SiT100A/) Trustee Trustee and Beneficiary same individual Ownership Interest # Select one Settlor/Grantor Settlor/Grantor and Beneficiary same individual Settlor/Grantor and Trustee same individual Settlor/Grantor, Beneficiary and Trustee same individual Beneficiary Partner (If Beneficiary or Partner is an Entity, append additional completed SiT100A/) Trustee Trustee and Beneficiary same individual Original - Branch Copy - Client Page 5 of 6

6 Ownership Select one Settlor/Grantor Settlor/Grantor and Beneficiary same individual Settlor/Grantor and Trustee same individual Interest # Settlor/Grantor, Beneficiary and Trustee same individual Beneficiary Partner (If Beneficiary or Partner is an Entity, append additional completed SiT100A/) Trustee Trustee and Beneficiary same individual F The undersigned authorized person certifies and agrees that: The above is a full and complete disclosure of information with respect to the above account holder and to all natural persons, entities, trusts and directors holding ownership interest (direct or indirect) in the above named account; We will maintain accurate up-to-date information respecting all beneficial owners by notifying Scotia Capital Inc. of material changes and provide confirmation and up-to-date information about beneficial owners as requested under the Proceeds of Crime (Money Laundering) and Terrorist Financing Act, Qualified Intermediary, Canadian Tax Regulations related to the Foreign Account Tax Compliance Act and Investment Industry Regulatory Organization of Canada regulations, or by an external auditor of Scotia Capital Inc. At the time of an external audit examination, we understand that we may be contacted by Scotia Capital Inc. and requested to provide to their auditors information on the current beneficial owners to validate that the current file at Scotia Capital Inc. is up-to-date and accurate, or to provide new information about beneficial owners as required, and agree to do so; The income to which this form relates is: (a) not effectively connected with the conduct of a trade or business in the United States, (b) effectively connected but is not subject to tax under an income tax treaty, or (c) the partner s share of a partnership s effectively connected income, and for broker transactions or barter exchanges, the beneficial owner is an exempt foreign person as defined in the instructions; We acknowledge that information contained in this form and information regarding my Scotia itrade Inc. account(s) (including information on account balances and payments received) may be reported to the Canada Revenue Agency (CRA), and that the CRA may provide the information to any additional country I have listed above as being a country in which I am a resident for tax purposes; The authorized person below has the capacity to sign this form for the beneficial owner(s) named on this form; and We will provide the required verification documents for this entity and the personal identity documents for authorized persons and individual beneficial owners and submit a new form within 30 days of such change in circumstances if any certification on this form becomes incorrect as required under current legislation and regulations. X Certification (Signature(s) required) Signature of Authorized Person Authorized Person Name Total Ownership Interest for section E (must equal 100) Date (mm-dd-yyyy) Position within organization (CEO, President, Secretary, Trustee, etc) X Signature of Authorized Person Authorized Person Name Date (mm-dd-yyyy) Position within organization (CEO, President, Secretary, Trustee, etc) Original - Branch Copy - Client Page 6 of 6